Ovarian Tumors PDF

OVARIAN CANCER by Prof. E.J. Cheserem 14/02/2022 Malignant Ovarian Tumours Introduction – Malignant ovarian tumours – present an increasing challenge in gynaecology. Cause more deaths than any female genital tract cancers. In USA about 26500 new cases are diagnos...

OVARIAN CANCER by Prof. E.J. Cheserem 14/02/2022 Malignant Ovarian Tumours Introduction – Malignant ovarian tumours – present an increasing challenge in gynaecology. Cause more deaths than any female genital tract cancers. In USA about 26500 new cases are diagnosed anually,and 14500 deaths occur anually, because of the disease. It accounts for 5% of all cancers in women. One in every 56 women,will develop the disease in their life time. Malignant Ovarian tumours Adjusted death rates due to cancer for selected sites in females in USA-year1920 to1991per 100000 female population Uterus 6.9 Breast 27.4 Ovary 7.9 Colon and rectum 15.8 Malignant Ovarian Tumours – Incidence in Kenya: Gynaecologic cancers(KNH) Choriocarcinoma 2oo1-37(10.6%) 2002-6(7.9%) Cancer of Cx // - 230(66.4%)// - 283(65.8%) Ovarian Cancer // -76(22.0%) // - 109(25.3%) Cancer Ut.body // -3(1.0%) // -4(1.0%) NB.Souce Records Office KNH. Histological Classification of Malignant ovarian neoplasms. Epithelial neoplasms (Most common 90%) – Serous cystadenocarcinoma 42% – Mucinous cystadenocarcinomas 12% – Endometrioid carcinomas 15% – Mesonephroid carcinomas 6% – Anaplastic carcinomas 17% Malignant Ovarian Neoplasms Histogenic Classification: 1-Neoplasms derived from coelmic epithelium A.Serous tumours B. Mucinous tumor C.Endometrioid tumor D.Mesonephroid(clear cell)Tumor E.Brenner tumor Undifferentiated carcinoma F.Carcinosarcom and mixed mesodermal tumor Malignant Ovarian Neoplasms. 11.Neoplasms derived from germ cells – A.Teratoma 1.Mature teratoma a.Solid adult teratom b.Dermoid cyst c.Struma ovari d.Malignant neoplasms secundarily arising from mature cystic teratoma 2.Immature teratoma(partly differentated B.Dysgeminoma C.Embryonal carcinoma D.Endodermal sinus tumor E.Choriocarcinoma F.Gonadoblastoma Malignant Ovarian Neoplasms 111.Neoplasms derived from specialised gona dol stroma A.Granulosa theca cell tumors 1.Granulosa tumors 2.Thecoma B.Sertoli- Leydig Tumors 1.Arrhenoblastoma 2.Sertoli tumor C.Gynandroblastom D.Lipid cell tumor Malignant Ovarian Neoplasms 1V.Neoplasms derived from nonspecific mesenchyme A.Fibroma,haemangioma,leiomyoma, lipoma B.Lympoma C.Sarcoma. V.Neoplasms metastatic to the ovaries A.Gastrointestinal tract(Krukenberg) B.Breast C.Endometrium D.Lymphoma Malignant Ovarian Tumours Incidence,Epidemiology and Aetiology. – Twentythree percent of gynaecological cancers are ovarian. – Fourtyseven percent of deaths due to gynaecological malignancies in USA are due to ovarian cancer. – 12 women out of 1000,who develop ovarian cancer in USA,only 2-3 are cured. – Occur at all ages. Malignant Ovarian Tumours Age Distribution:The majority between the age of65- 85.Laregest group 60-85 years. At KNH. – Age Distribution. 1-9 years- 1.7 percent 10-19yrs- 1.7 percent 20-29yrs- 10.0 percent 30-39yrs- 8.3 percent 40-49yrs- 18.3 percent 50-59yrs- 30 percent 60-69yrs- 10 percent 70-79yrs- 1.7 percent 80-89yrs- 1.7 percent Unknowned-16.6 percent Source.Ojwang et al. Malignant Ovarian Neoplasms Cont. Germ cell tumors mainly in younger age group Epithelial tumors are seen mostly above 50yrs Most patients in Kenya are seen with advanced disease Stage Distribution at KNH. – Stage 1 and 11 11percent – Stage 111 and 1V 80percent Unstaged 8.3 percent Malignant Ovarian Tumours Aetiology – Familial predisposition 1.4 percent lifetime risk, with one first degree relative 5 percent and two or more relatives 7 percent. Associated with breast ovarian syndrom,seen in BRCA -1 and BRCA-2 genes,and transmitted as autosomal dominant.Risk of 50 percent can be expected. – Enviromental factors.Higher in developed countries but low in Japan – Others Combined oral contraceptives reduce the risk(Casagrande et al 1979) Long time use of clomid (Rossing MA.et al 19914) Low parity, nulliparous 2.9 more likely to have boaderline malignancies,reduced to 1.27 in those who have been pregnant at least ones Late age at menopause(Parazzini et al 1984) Chemical substances via the vagina(Woodroof et al.,Cramer et al) Malgnant Ovarian Neoplasms Incidence and death rate of ovarian cancer for various countries Country Incidence per Death rate 100000 per100000 Sweden 14.9 12.9 Norway 14.2 9.5 USA 13.3 7.3 Israel 12.7 GermanyDR 11.8 11.0 West Germany11.5 11.1 UK 11.1 9.1 Switzeland 10.6 Finland 7.9 Brazil 6.1 Japan 2.7 2.1 Nerthalands 12.1 From Heinz AP.et al:1985 Malignant Ovarian Neoplasms Signs and Symptoms: – No definite sypmtoms.Can present as a surgical problem or internal medical problem – Vague abdominal discomfort – Frequency of micturation – Urinary frequency – Pelvic pressure – Mass in the lower abdomen >15cm.suspect those between 40-69yrs Malgnant Ovarian Neoplasms Presenting Symptoms KNH Abdominal pain 8.3 percent Abdominal swelling and pain 15 percent Abdominal swelling 70 percent Vaginal bleeding 5 percent Others 1.7 percent Malignant Ovarian Neoplasms No methods for early diagnosis Tried aspiration of POD Immunological methods eg.CA 125(non specific) Abdominal ultrasound(doesn’t affect mortality) Better target those at risk Use multiple method to asses(routine screening can result in unnecessary surgery) Pelvic examination most important(detects only one case in every 10000 asymptomatic women Pain a late symptom in early cases,torsion or infection may occur Any ovary palpable 3yrs or more after menopause should be suspected Solid mass,> 5cm.and or papillary grouths suspect do laparoscopy if necessary exploratory laparatomy Routine lab. Tests of little value Ultimately laparatomy biopsy and cytology(50percent of ascitic fluid will be negative) Malignant OvarianNeoplasms Complete work up for ovarian cancer – Careful History – Physical examination – Pelvic examination and pap smear – Proctosigmoidoscopy – CBC and urinalysis – Blood chemistries, including CA-125 – Chest X-Ray – IVU – Barium enema or CT scan with contrast – Pelvic ultrasound Malignant Ovarian Neoplasms Differential Diagnosis – Ovary:Functional cyst ❖ Neoplastic cyst Benign Malignant Endometrriosis Solid:Neoplasm Benign Malgnant _ Fallopian Tube cystic:Tuboovarian abscess Hydosalpinx Paraovarian cyst solid: Tuboovarian abscess Ectopic pregnancy Neoplasm _Uterus Intrauterine pregnancy in abicornuate uterus Pendunculated or interligamentous myoma _Bowel Gas or and Feces Divarticulitis,Appendicits,Ileitis,Collon Cancer _Miscelaneus - Distended bladdre Pelvic kidney Urachal cyst Abdominal wall haematoma,abscess, Retroperitoneal neoplasm Malignant Ovarian Neoplasms Staging at laparotomy – Stage 1.Growth limited to the ovaries – Stage 11.Grouth involving one or both ovaries with pelvic extension – Stage 111.Tumour involving one or both ovaries with peritoneal implants outside the true pelvis and or positive retroperitoneal or inguinal nodes,superficial liver metastasis equals stage 111, Malignant Ovarian Neoplasms Guidelines for staging in Epthelial Ovarian Cancers 4 peritoneal washings(diaphragm,right and left abdomen,pelvis) Careful inspection and palpation and inspection of all peritoneal surfaces Biopsy or smear from undersurface of right hemidiaphragm Biopsy of all suspicious lesions Infracolic omentectomy Biopsy or resection of any adhiesions Random biopsy of normal peritoneum bladder reflection,POD,right and left paracolic recesses,and both pelvic side walls(in the absence of obvious implants) Selected lymphadenectomy of pelvic and paraaortic nodes TAH.BSO. And excision of all masses where possible Malignant Ovarian Neoplasms Pelvic findings in benign and malignant ovarian tuours Clinical findings Benign Malignant Unilateral +++ + Bilateral + +++ Cystic +++ + Solid + +++ Mobile +++ + Fixed + +++ Irregular + +++ Smooth +++ + Ascites + +++ POD-nodules + +++ Rapid growth + +++ Malignant Ovarian Neoplasms Surgical Treatment in Ovarian Cancer – 1.Peritoneal cytologic examination – 2.Determination of extent of the disease ❖ a.Pelvis ❖ b.Peritoneal surfaces ❖ c.Diaphragms ❖ d.Omentum ❖ e.Lymphnodes – 3.Remove all tumour possible(totalabdominal hysterectomy and bilateral salphingoophorectomy plus node sampling and omentectomy) Malignant Ovarian Neoplasm Chemotherapy – Taxol(Paclitaxel) – Cisplatin – Carboplatin – Melphalan – Cyclophosphamide NB.Some of these drugs are highly emetogenic.Premedication may be required with:- Dexamethason Diphenhydramine Cimetidine or ranitidine Malignant Ovarian Neoplasms Chemotherapy:Drug Toxicity – Mainly on rapidly deviding cells Haematological Gastrointestinal Skin Hepatic Lungs eg.Interstitial pneumonitis Cardiac Genitourinary Neurological Gonadol dysfunction Malgnant Ovarian Neoplasms Radiotherapy Some ovarian cancer can respond to radiotherapy eg.Dysgeminomas Radiotherapy in ovarian cancer is limited by large area to be treated,which may lead to serious complications – Special Problems ❖ Limits of spread often unknowned ❖ Viability of radiosensitivity ❖ Total burden often very large ❖ Free mobility of tumour cells within the abdominal cavity ❖ Radiation doses restriced by neighboring organs ❖ Infrequent detection of early disease Malignant Ovarian neoplasms Radiotherapy Dose Restrictions.Tolerance of small intestines.Limited tolerance of kidneys. Bone marrow depression. Radiation enteritis caused by large volume of intestine irradiated. Athesive peritonitis Malignant Ovarian Neoplasms Supportive treatment – Pain relief – Nutritional therapy – Blood therapy – Counselling,the patient and relatives Malignant Ovarian Neoplasms Screening No definete method – Frequent pelvic examination – Aspiration of POD for cytology – Ultrasonography and other imaging methods – CA-125 – Malignant Ovarian Neoplasm Five year survival Stage Survival percent Stage 1a 84% Stage 1b 79% Stage 1c 73% Stage 11a 65% Stage 11b 54% Stage 11c 61% Stage 111a 52% Stage 111b 29% Stage 111c 18% Stage 1V 14% NB.The overall 5yr. Survival was 31% Total 6118pts. Source:FIGO annual report.Vol 22,1994. Malignant Ovarian Neoplasms THE END THANK YOU